2.0 Analysis 2.1 Loss of Paravane Although there is no evidence to indicate that such was the case in this occurrence, instances are on record where the loss of a paravane on one side was one of the contributing factors to the capsizing of a vessel. The parting under stress of the wire or chain holding the port paravane would result in a starboard list. In such an event, the starboard paravane would act as a drag and cause the vessel to swing to starboard. 2.2 Use of Poundboards and Safety The purpose of freeing ports is to facilitate rapid drainage of sea water shipped on deck. As the poundboards were in place and were not fitted with means such as drain holes/slots to facilitate the drainage of water, shipped sea water was retained on deck and the rate at which the water could escape through the freeing ports was slowed. The poundboards were not dismantled and stowed below-deck upon completion of fish-loading operations, even though north-west winds had been forecast to increase to 15 to 25kn by morning with 2 to 3m seas, and the outlook called for strong northerlies. Because of the time required to dismantle/ship the poundboards on deck, the crew had adopted a practice of keeping the poundboards in position even when not in use. The hazard associated with such a practice was not fully appreciated by the crew. 2.3 Free Surface Effect Whenever there is a free surface due to liquids on board a vessel, there is a loss of effective metacentric height (GM) due to a virtual rise of the vessel's centre of gravity, as well as a loss of transverse stability caused by the movement of the liquid in partially filled compartments and/or of the shipped water on deck when the vessel rolls. This movement may involve a large shift of weight. In this instance, the free surface effect was generated by the shipped water retained on deck and the accumulation of sea water in the forecastle and after accommodations. As the vessel had replenished fuel and water the day before the accident, the free surface effect resulting from the consumables is considered to have been minimal. In general, few fishermen fully understand free surface effect and fewer appreciate the substantial loss of transverse stability that occurs when water, even a few inches, is shipped and retained on deck. Coupled with the loss of effective water plane area when the deck edge is submerged, the effects can be disastrous. 2.4 Penning of Fish Holds Although not required by regulation, the fish holds on the PACIFIC BANDIT were fitted with pen boards. Pen boards limit the movement of weights over a large area, thereby reducing the free surface effect of fish loaded in the compartment. Pen boards also limit/restrict the angle of heel associated with the large movement of weights (fish). The arrangement of pen boards in the fish hold was such that the top of the cargo could shift transversely whenever cargo was loaded to or above the height of the pen boards. The resultant transverse shift of weight as the vessel rolled in the seas would have further increased the vessel's list. This situation would have been further complicated when sea water mixed with the fish cargo and facilitated its movement. The sea water had entered the compartment from the deck scuttles due to the poor condition of their seals. For maximum effectiveness, the pen boards must extend well above the level of fish in the compartment. In this instance, the height to which the athwartship pen boards could be fitted, of necessity, had to be limited to facilitate the fish loading process because only four deck scuttles and an access hatch in the cover were available to load fish into the forward hold. However, similar limitations would not have applied to the fore-and-aft pen boards. The fitting of fore-and-aft pen boards as close to the deckhead as practicable would have mitigated the adverse effects of a shifting load on the vessel's transverse stability. At the same time, the fish-carrying capacity of the compartment would have been maximized. 2.5 Factors Affecting Stability When the vessel was headed into the wind and seas, she commenced shipping sea water on the forward deck. The vessel's roll to starboard would have caused the cargo to move to starboard, increasing the starboard list. By the time the engineer stepped onto the deck, about 0.3m of sea water had accumulated on the starboard side, and the weight of the water further outboard would have aggravated the list. As the list increased, the freeing ports on the starboard side submerged. This would have further retarded the rate at which sea water could be cleared from the deck. The additional weight of sea water shipped and retained on deck would have further aggravated the situation and progressively increased the heel. The situation was further compounded by the movement of the fish in the fish hold. Because the doors to the forecastle and after accommodations were open, downflooding of the below-deck compartments occurred. The application and maintaining of hard-a-port helm and the increase in engine rpm aggravated the situation because the centrifugal forces generated by the turn to port would have caused all slack liquids to gravitate to starboard. This suggests that the forces generated by manoeuvring the vessel and the free surface effect of shipped water and other liquids, in conjunction with the movement of the fish in the fish hold, were such that they overcame any righting ability of the vessel. All positive transverse stability was lost and the vessel capsized. The damage to the galley windows accelerated the flooding of the accommodation and below-deck spaces, which continued until all reserve buoyancy was lost and the vessel sank. 2.6 Condition of the Deck Scuttle Seals The life expectancy of such seals depends on a number of factors, including the material of construction, the frequency of use, and the climatic conditions under which the vessel is operating. The sinking of the vessel precluded any examination and, as such, the precise condition of the deck scuttle seals at the time of the accident could not be established. However, based on the statements provided by the ship's crew, the condition of the deck scuttle seals was such that water could enter the fish hold. The fact that the crew had discussed replacing the seals would suggest that the seals may have been in a deteriorated condition for a period of time. The PACIFIC BANDIT had been inspected by the CCG SSB eight months previously and a full-term (four-year) certificate was issued. Although a S.I.7 was issued for other items, no reference was made to the deck scuttle seals. The absence of a S.I.7 would suggest that the watertight integrity of the seals was not compromised at the time of the inspection. Two commonly used methods of checking the watertight integrity of deck scuttle seals are to subject the scuttles to a hose test or, alternatively, to pressure test the compartment, the former being the most commonly used method. In any event, for the scuttle seals to be leaking within a period of some eight months from inspection, a rapid and substantial deterioration of the seals had to have taken place. There is no evidence to suggest that the PACIFIC BANDIT was operated in other-than-normal conditions. In the absence of records indicating the material of construction and the date that the seals had been replaced, it is not possible to determine the precise condition of the seals at the time of the ship inspection. 2.7 Inflatable Liferaft and Safety As liferafts on small fishing vessels are positioned close to the sea level, crews fear that liferafts could be dislodged from their stowed position. Some fishing vessels use additional rope lashings to secure the liferafts. However, liferafts need to be launched during emergencies when time is of the essence, and it is imperative that any securing arrangement be such that the liferaft can be launched expeditiously and safely. In this instance, the liferaft on the PACIFIC BANDIT was secured with additional rope lashings but did not have a quick-release mechanism, nor was a knife ready at hand. Securing Arrangement for Entrance Covers In cold climatic conditions such as those experienced in Canada, it is essential that the personnel in the inflatable liferaft be protected against the elements. The inflatable liferaft standards require that the closing arrangement for the entrance covers be designed such that the covers can be easily and quickly opened from the inside and outside in all weather conditions. However, the crew experienced difficulty in handling the tie tapes in the cold weather. This would suggest that an alternative and/or supplementary means of securing the entrance covers may increase survival capability. Method of Inflating the Liferaft During abandonment, the cumulative effect of the anxiety resulting from the situation and the loss of valuable time associated with hauling the length of the painter to inflate the liferaft may decrease the survival time of a non-swimmer. An alternative or supplementary method of inflating the liferaft, as is currently fitted on some liferafts, could prevent valuable time from being lost and maximize the crew's chances of survival. Liferaft and Liferaft Equipment Servicing Although the flashlight batteries are always replaced at the time of annual servicing, the flashlight did not function. As the flashlight was not available for examination after the accident, the precise cause of the problem could not be established. The quality control regime of the servicing depot would appear to have been less than optimal because: of the shortcomings revealed by the post-occurrence inspection of the liferaft; and of the TSB Engineering Laboratory findings that the corrosion at the battery terminals to the dome light had occurred over an extended period of time. 2.7.1 Emergency Drills Because MED training is not a prerequisite for crews employed aboard fishing vessels of this size and type, it is imperative that the skippers conduct emergency drills and ensure that their crews know where the life-saving equipment and fire-fighting appliances are stowed, are knowledgeable in their use, and are aware of their duties and responsibilities during emergencies. 2.8 Location of EPIRB As it is essential to take an EPIRB into the liferaft at the time of abandonment, the EPIRB must be strategically positioned in the wheel-house for immediate access. On this occasion, the EPIRB, which was in the skipper's cabin, had become inaccessible due to flooding when the skipper was forced to abandon ship; consequently, the EPIRB remained on board. 3.0 Conclusions 3.1 Findings When the vessel was headed into the wind and seas, she began to ship sea water on deck. The poundboards in position on deck were not fitted with a means to rapidly drain the sea water accumulating in the pounds. The poundboards were not removed until the vessel had developed a significant starboard list. The crew did not appreciate the hazard associated with the practice of leaving the poundboards in position when not engaged in fishing operations. The condition of the seals of the two after deck scuttles to the forward fish hold was such that some of the sea water that had accumulated on deck leaked into the hold. The pen boards in the forward fish hold did not extend to the deckhead, and the sea water entering the hold through the scuttles facilitated the free movement of the fish in the hold as the vessel rolled. The vessel developed a starboard list which progressively increased due to the cumulative effect of the sea water shipped and retained on the starboard side of the main deck and of the cargo shifting to starboard. The increase in list progressed to the point where the freeing ports on the starboard side became submerged, rendering them ineffective. The crew did not fully appreciate the cumulative effect on the vessel's stability of the free surface effect generated by the sea water on deck and in the forecastle and after accommodations. The forces generated by manoeuvring the vessel, the free surface effect of liquids, and the movement of the fish in the hold were such that they overcame the vessel's ability to right herself. The vessel capsized when all positive transverse stability was lost. Downflooding through the open accommodation doors and the damaged galley windows continued until the vessel lost reserve buoyancy and sank. When abandoning the vessel, the engineer was the only crew member wearing an immersion suit. None of the crew donned a lifejacket. No emergency drill had been practiced since the crew members who survived had joined the vessel, and some of the crew did not know where the lifejackets and immersion suits were stowed. There is no requirement for uncertificated crews to undergo Marine Emergency Duties (MED) training. The Emergency Position Indicating Radio Beacon (EPIRB) located in the skipper's cabin was neither activated nor taken aboard the liferaft. Valuable time was lost in launching the inflatable liferaft because the raft was secured by additional rope lashings which were not fitted with a quick-release mechanism. The crew members in the liferaft could not find the liferaft knife in darkness and were unable to quickly cut the liferaft painter or to go immediately to the assistance of the other crew in the water. Because their fingers were numb with cold, the crew members in the liferaft experienced difficulty in tying the tapes to close the entrance covers. The inflatable liferaft had been serviced by a credited servicing depot eight months before the accident, but its dome light and flashlight did not operate. 3.2 Causes While operating in moderate sea conditions, the PACIFIC BANDIT capsized when positive transverse stability was lost due to the cumulative effect of the shipped seas retained on deck, the stowage of the catch, the free surface effect of liquids, and downflooding to the below-deck spaces. The open weathertight doors and the broken galley windows accelerated the downflooding, which continued until the vessel lost all reserve buoyancy and sank. 4.0 Safety Action 4.1 Action Required 4.1.1 Stability of Small Fishing Vessels At the time of the occurrence, the PACIFIC BANDIT was fully loaded, with a relatively low freeboard. The adverse weather conditions and following seas caused large waves to be shipped over the stern. A hazardous situation was created as a result of several deficiencies existing on the PACIFIC BANDIT: the poundboards had no means of draining sea water; the poor condition of the deck scuttle seals allowed sea water to leak into the fish hold; and the free movement of the fish above the pen boards in the hold reduced the transverse stability as the vessel rolled. The adverse conditions affecting the seaworthiness of the PACIFIC BANDIT just before the sinking were similar to those identified in several other occurrences(6) over the past five years. All of these occurrences involved small fishing vessels, the crews of which apparently had little knowledge of, or concern about, the factors affecting vessel stability. At present, small fishing vessels, except those engaged in the herring or capelin fishery, are not required to have their stability evaluated, nor are the crews and operators required to demonstrate a knowledge and skill in the operation of these vessels. Small fishing vessels make up the vast majority(7) of the Canadian fishing fleet, and in the last decade, 238 fishing vessels of less than 150 gross registered tons (GRT) have capsized or foundered in Canadian waters; more than two thirds of them were less than 15 GRT. In the western region alone, an average of 12 small fishing vessels have capsized or foundered annually, resulting in a total of 20 fatalities. The Canadian Coast Guard (CCG) has issued numerous safety publications on vessel stability and unsafe operating practices. As evidenced by the aforementioned statistics, the message is not getting out to those who are actually operating and crewing the vessels. It is the Board's belief that many operators do not perceive their operating practices as unsafe; in fact, some practices may not appear to be unsafe, especially in favourable operating conditions. However, in adverse weather and seas, these same practices can quickly jeopardize vessel stability and often result in capsizings. The Board acknowledges that Transport Canada (TC) is in the process of replacing the Small Fishing Vessel Inspection Regulations (SFVIR) with the proposed Small Fishing Vessel Safety Regulations (SFVSR). One of the long-term objectives of the proposed regulations is to have a stability booklet for all fishing vessels over 15m in length. However, given that many crews on fishing vessels may not fully appreciate that their day-to-day operating procedures and some seemingly minor vessel defects may be creating unsafe conditions, the Board recommends that: The Department of Transport, in conjunction with other government departments, agencies, and organizations, immediately undertake a national safety promotion program for operators and crews of small fishing vessels to increase their awareness of the effects of unsafe operating practices on vessel stability. For the longer term, the Board further recommends that: The Department of Transport conduct a study to identify the extent of unsafe loading and operating practices used by fishermen on small fishing vessels, with a view to developing guidelines for the safe operation of small fishing vessels. 4.1.2 Chances of Survival of the Crew on Fishing Vessels Following its investigation into the sudden capsizing of the fishing vessel STRAITSPRIDEII (TSB Report No.M90N5017), in which three crew members failed to successfully abandon the vessel, the Board made two recommendations relating to the chances of survival of the crew on fishing vessels. The Board recommended that: The Department of Transport ensure that personnel who regularly crew closed-construction fishing vessels receive formal training in life-saving equipment and survival techniques; and The Department of Transport expedite its revision of the Small Fishing Vessel Safety Regulations which will require the carriage of anti-exposure worksuits or survival suits by fishermen. In response, TC issued Ship Safety Bulletin No.6/95 emphasizing the importance of carrying the recommended life-saving appliances on board small fishing vessels, and the training of personnel in their use. The Bulletin also encouraged all seafarers to obtain the necessary training and retain their skills through on-board practice. In addition, TC advised that the proposed revised SFVSR will require anti-exposure worksuits as alternative equipment. Until the promulgation of the SFVSR, the CCG has indicated that it will promote the voluntary carriage of anti-exposure worksuits. The frequency of small fishing vessel capsizings continues to be cause for concern. These capsizings continue in spite of considerable safety action to correct identified safety deficiencies. Notwithstanding the Ship Safety Bulletin and the promotion of anti-exposure worksuits, the Board notes that the survival of fishermen is still being jeopardized due to a lack of knowledge and training in the use of available life-saving equipment. The message is not getting through. Thus, the Board believes that further action in response to earlier TSB recommendations on formal training in life-saving equipment and survival techniques (M92-06) and on the carriage of anti-exposure worksuits/survival suits (M92-07) is necessary. Therefore, to ensure that fishermen have a reasonable expectation of survival following abandonment, the Board recommends that: The Department of Transport explore alternative means of communication to encourage crews of small fishing vessels to train in the use of life-saving equipment. In the past one and one-half years, at least four fishing vessel occurrences, in addition to this one, were reported to the TSB in which problems regarding the use of liferafts were identified. In April 1995, the 44-ton fishing vessel HILI-KUM sank; two of her crew drowned when the liferaft capsized. In November 1995, the 27GRT fishing vessel LADYCANDACE capsized and sank rapidly; the liferaft had to be cut free from the securing lashings, and none of the crew knew that the raft was outfitted with a knife. On the same day, the SIMON JACQUES sank, taking the liferaft down before the crew had time to deploy it. In March 1996, a fire broke out on the 12m fishing vessel LITTLE BRAT; when the raft was deployed, the crew was only able to get the top buoyant chamber inflated. The survival of crews when abandoning ship at sea depends largely on the capability and reliability of their survival equipment, as well as on their familiarity and skill in using that equipment. The Board previously addressed shortcomings in the design of liferafts with respect to ease of boarding (TSB Recommendation M93-12) and their stowage and accessibility (TSB Recommendation M93-03). However, as noted in the above occurrences, crews' lack of familiarity with the use of liferafts continues to put seafarers at risk. Therefore, the Board recommends that: The Department of Transport encourage the owners and crews of small fishing vessels to conduct realistic emergency abandonment drills on a regular basis.